Monday, May 15, 2006

Living Will, Living Won't

Interesting letter in the ST Forum today on the subject of Advanced Medical Directive (AMD):

May 15, 2006Doc won't witness medical directive

MY WIFE and I, aged 73 and 80 respectively, read in The Sunday Times that one can make a legal directive stating that if one is terminally ill and in a coma with no hope of recovery, no life sustaining treatment should be given ('When death strikes'; ST, April 16).So my wife, who is a stroke victim, and I went to the nearest doctor, each with a prepared advance medical directive, with our daughter who was to be a witness, with a request for the doctor to be the second witness. It was stated in the article that two witnesses are required, one of whom must be a registered medical practitioner.

Imagine my surprise when the doctor declined to be a witness, saying it is not clear she is empowered to do that. She also said that as we had no medical records at her clinic, she could not witness our signatures. In my wife's case, she suggested she go to Tan Tock Seng Hospital where she was admitted for her stroke and ask a hospital doctor to be her witness as her records are there. She suggested I go to Ang Mo Kio Polyclinic as I was treated there for asthma.

From my observations, I believe ours was the first such request this doctor has had, as the advance medical directive is new, and I suspect she decided to play safe and not get involved.

There must be many elderly poor who want to make an advance medical directive, but are either unaware that such a scheme is available or don't know how to do it.

Can the authorities kindly enlighten us what one has to do to get an advance medical directive validated?

Trevor Reginald

Mr Reginald's letter contains a couple of inaccuracies:

1. The AMD is not something new, but has been around for 10 years.

2. The doctor is the first witness, and his daughter, being someone who may stand to gain from his death, cannot be a witness.

Of course he cannot be faulted for the misconceptions; in fact this proves his point about the general ignorance about the existence of such a law. You can find out more about the AMD (or 'Living Will') from the MOH website.

I won't be surprised if the doctor had, as Mr Reginald suspected, never witnessed an AMD previously. I don't think I have witnessed more than two or three AMDs in the ten years that the law has been passed. In any case, a doctor can actually refuse to witness an AMD if he registers his objection with the Registrar, or if he does not believe that the patient fulfills the criteria for an AMD.

If I were the doctor, I too would have been reluctant to witness an AMD for someone who had just read about it in the newspaper and decided to go to the nearest clinic to have one signed. A doctor has the duty to make sure that the patient understands the nature and consequences of an AMD, and also that he or she is not under any compulsion to sign one - hardly something you can be certain of for someone you see for the first time.

I have actually been thinking about the topic over the weekend because I have just witnessed an AMD for a patient last week. I am not his family doctor (like many Singaporeans he did not have a 'family doctor'), but he had seen me a few times previously for his chronic medical condition, and at the age of 73, had decided that he would plan for his eventual death. He did not want to burden his family in the event that he would require "extraordinary life-sustaining treatment" when death is imminent. He understood the nature and consequences of the AMD, and had thought the matter over.But there was a slight problem - he had not discussed the matter with his family. I told him his family would most likely feel hurt that he had not discussed the issue with them, but he was determined to keep the AMD from his family. One does not require a family's consent to sign an AMD. I witnessed his AMD.

That same afternoon his son actually came back to see me, hoping to find out why his father had asked him not to accompany him into the consultation room like he had always done before. I told him he had to ask his father himself.

"But he wouldn't tell me!"

I knew that was going to happen - people often underestimate their family members' ability to tell that something is 'wrong' with them. I told him that as an adult of sound mind his father was entitled to privacy of his medical status and I could not reveal any information without his consent. I encouraged him to continue to talk to his father. The poor man probably went home thinking his father has cancer or something.

Curiously, I have never seen an AMD 'in action', as it were. Most of the ICU patients whose treatment I was involved in either got well, or died before the issue of an AMD was even brought up. Still, it would be interesting to see what further discussion Mr Reginald's letter would generate.

True. Unfortunately the other truth is that most Singaporeans cannot afford to pay for the ICU care while waiting for miracles to happen (if they happen).

Otherwise I don't see why the hospital would be unhappy to keep lots of patients on ventilators all over the place, earn nice profits while doing very little actively everyday.

Try going to the private hospitals and I'm sure they will have no objections to letting people stay on ventilators waiting for miracles to happen if they can afford to pay the charges indefinitely.

There is also the matter of how much the patient actually suffers. This one we will never know because these patients are unable to make the call by the time they reach that stage.

So uglybaldie, be careful what you wish for and not wish for. Who knows there might come a time when you are cursing yourself in some subconscious slumber in some ICU for not signing that damn AMD while your hard earned money is going down the drain, because your relatives are saying "Miracles do happen that medical science cannot explain" and since we can afford it, we will hold out for as long as there is hope, and you are in terrible pain day in day out. day in , day out, day in, day out.....

huh? You mean to say that in a country like Australia where medical care is free, they still have AMD? Countries with AMD are as miserly as us.

Only duffers will sign if it's free.

I really don't understand why the two elderly couple in question were that keen to sign. Their children owe it to them to take good care of them even if it means scrimping on that new car or apartment. And it is quite obvious that they have not bought adequate insurance when they were younger.

Frankly, what's a few ventilators running on our cheap electricity going to cost? Get Mediacorpse to do a few tear jerking fund raisers ala monk style and you will have a few dozen brand neuw, shiny ventilators ready to be mobilized.

Anyway, if you are STILL not sure about the pain and suffering thingy after having spent so many years in our ahem, world famous medical school, then I guess, to err on the side of safety is best. Keep 'em alive, that's what I would do.

Everything is defined very specifically. AMD is only applied for patients with "terminal illnesses" and this is defined in the FAQ.

Uglybaldie, go read it lah. The link is on angrydr's blog entry.

Some of the questions answered are

What is an Advanced Medical Directive?What is meant by "terminal illness"What is meant by "extraordinary life sustaining treatment"? Who can make an AMD? How do I make an AMD?Is the AMD a type of euthanasia or mercy killing?Does the AMD Act encourage euthanasia?Who can certify that a person is terminally ill?What happens if the panel of doctors cannot reach a unanimous decision?Do I have to pay for the services of the second panel of 3 specialists appointed by MOH?Can an AMD take effect is the second panel of doctors also cannot agree on the diagnosis?If a patient who has made an AMD suffers from terminal illness, will he/she be left without medical treatment or left to starve?What safeguards are there to ensure that I am given all the necessary treatment before the AMD is carried out?If I change my mind about an AMD which I have made earlier, can I revoke it?What is my condition is such that I am unable to write?What if I do not have an AMD?

All in all there are 34 questions that are answered in the booklet I have from MOH.

Go read it lah uglybaldie. Actually MOH has done a good job making things an unambiguous and possible.

I have neither the inclination nor the appetite to read unpleasant stuff. Gimme the online editions of "Playboy" or "Penthouse" magazines anytime.

I still maintain that it is not the done thing to do, to pull out the plug despite and inspite of every arguement to the contrary. I'm just wondering in such circumstances, who has the unenviable task of switching off the machines. May his soul rest in peace!